SNRI Toxicity: Difference between revisions
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==Background== | ==Background== | ||
*Inhibits reuptake of serotonin, norepinephrine and small effect on dopamine | *Inhibits reuptake of serotonin, norepinephrine and small effect on dopamine | ||
**Examples: venlafaxine, duloxetine | **Examples: [[venlafaxine]], [[duloxetine]] | ||
*Adverse effects similar to [[SSRIs]] | *Adverse effects similar to [[SSRIs]], but more dangerous | ||
*Venlafaxine (Effexor) | *[[Venlafaxine]] (Effexor) | ||
**Can produce mild to moderate hypertension | **Can produce mild to moderate hypertension | ||
*Duloxetine (Cymbalta) | *[[Duloxetine]] (Cymbalta) | ||
**Nausea, vomiting, dizziness | **Nausea, vomiting, dizziness | ||
==Clinical Features== | ==Clinical Features== | ||
*Sympathomimetic: tachycardia, hypertension, diaphoresis, tremor, mydriasis | *Sympathomimetic: tachycardia, hypertension, diaphoresis, tremor, mydriasis | ||
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*[[Seizures]] | *[[Seizures]] | ||
**More common than with [[SSRI toxicity]] | **More common than with [[SSRI toxicity]] | ||
**Also common with [[venlafaxine]] and [[bupropion]] | |||
*[[Rhabdomyolysis]] | *[[Rhabdomyolysis]] | ||
**25% occur without seizures | **25% occur without seizures | ||
*ECG | *[[ECG]] | ||
**Most common abnormality: sinus tachycardia | **Most common abnormality: sinus tachycardia | ||
**May see QRS widening | **May see QRS widening, QT prolongation and ventricular dysrhythmias | ||
== | *[[Serotonin syndrome]] | ||
==Evaluation== | |||
*Suggestive history with appropriate clinical features | *Suggestive history with appropriate clinical features | ||
*[[ECG]] | |||
*Assess for [[rhabdomyolysis]] | |||
==Management== | ==Management== | ||
*Cardiac monitoring | *Supportive Care | ||
* | **Cardiac monitoring | ||
* | ***[[Sodium bicarbonate]] if widened QRS | ||
*** IV fluids for hypotension ([[norepinephrine]] if refractory) | |||
**[[Benzodiapazines]] for seizures | |||
**GI Decontamination | |||
***A single dose of [[activated charcoal]], 1 g/kg (typical adult dose is 50 g), may be given to a patient who presents within one to two hours of ingestion. | |||
***AC should not be given to patients at risk for aspiration | |||
==Disposition== | ==Disposition== | ||
*Admit all symptomatic | *Admit all symptomatic patients to a monitored bed | ||
*Monitor for 6 hours, longer for extended-release preparations | *Monitor for 6 hours, longer for extended-release preparations | ||
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*Mills K. Atypical Antidepressants, Serotonin Reuptake Inhibitors, and Serotonin Syndrome In: Tintinalli's Emergency Medicine. 7th ed. McGraw Hill. 2011:1198-2002 | *Mills K. Atypical Antidepressants, Serotonin Reuptake Inhibitors, and Serotonin Syndrome In: Tintinalli's Emergency Medicine. 7th ed. McGraw Hill. 2011:1198-2002 | ||
[[Category: | [[Category:Toxicology]] | ||
Latest revision as of 19:08, 15 February 2021
Background
- Inhibits reuptake of serotonin, norepinephrine and small effect on dopamine
- Examples: venlafaxine, duloxetine
- Adverse effects similar to SSRIs, but more dangerous
- Venlafaxine (Effexor)
- Can produce mild to moderate hypertension
- Duloxetine (Cymbalta)
- Nausea, vomiting, dizziness
Clinical Features
- Sympathomimetic: tachycardia, hypertension, diaphoresis, tremor, mydriasis
- Secondary to inhibition of norepinephrine reuptake
- Sedation
- Seizures
- More common than with SSRI toxicity
- Also common with venlafaxine and bupropion
- Rhabdomyolysis
- 25% occur without seizures
- ECG
- Most common abnormality: sinus tachycardia
- May see QRS widening, QT prolongation and ventricular dysrhythmias
- Serotonin syndrome
Evaluation
- Suggestive history with appropriate clinical features
- ECG
- Assess for rhabdomyolysis
Management
- Supportive Care
- Cardiac monitoring
- Sodium bicarbonate if widened QRS
- IV fluids for hypotension (norepinephrine if refractory)
- Benzodiapazines for seizures
- GI Decontamination
- A single dose of activated charcoal, 1 g/kg (typical adult dose is 50 g), may be given to a patient who presents within one to two hours of ingestion.
- AC should not be given to patients at risk for aspiration
- Cardiac monitoring
Disposition
- Admit all symptomatic patients to a monitored bed
- Monitor for 6 hours, longer for extended-release preparations
See Also
References
- Mills K. Atypical Antidepressants, Serotonin Reuptake Inhibitors, and Serotonin Syndrome In: Tintinalli's Emergency Medicine. 7th ed. McGraw Hill. 2011:1198-2002